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What my patients have said ...

Dear Mr Tailor… I would like to thank you, your pleasant and very efficient secretary and everyone I met for assessment at day surgery. Although you all are caring for many people, there was time for each patient – explaining and comforting – no rush. Thank you all for making this a positive experience.

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Ovarian Cysts

Ovarian cysts or lumps are quite common and only a minority turn out to be cancerous! In women less than 50 years of age, probably less than 10% of cysts are sinister. In those above 50 years, less than 30% are cancerous.

ovarian cyst
Benign ovarian cyst

In young women (< 50 years) cysts are often discovered incidentally on scan. Usually these disappear by themselves within 6 to 8 weeks and hence all they require is a repeat scan after that interval. Those that persist can often be treated with key-hole surgery if the impression is that of a non-cancerous cyst.

In older women, if the impression is that of a non-cancerous cyst then, once again, the ovaries are removed by key-hole surgery. Otherwise, open surgery is carried out in order to remove the ovarian cysts in an intact fashion. It also allows a hysterectomy and other biopsies to be carried out safely. These other biopsies include removal of the omentum (apron of fatty tissue), lymph glands and occasionally the appendix.

Therefore it is crucial that the person carrying out the scan has the expertise to discriminate cancerous and non-cancerous cysts. Patients who come to see me are usually scanned by myself during the consultation.

At the consultation, a blood test called CA125 tumour marker may be carried out. This can add value to the overall impression as to whether a cyst is likely to be cancerous or not. It is elevated in 85% of all ovarian cancers. However only 50% of early stage ovarian cancers (stage 1) have an abnormal level. Hence, 50% of early ovarian cancers have a normal level. Furthermore, 30% of non-cancerous cysts have an abnormal value! Therefore, it can be inaccurate and its limitations need to be understood.

Ovarian Cancer

The risk of an ovarian cyst turning out to be cancerous increases with age. Hence when large cysts are found after the menopause, they are usually removed. If there is a strong suspicion that the cyst, even if found after the menopause, is benign then it can be removed by key-hole surgery. These benign cysts are punctured and have their fluid content sucked out so that they can be squeezed out of the small holes made for key-hole surgery.

When the nature of the cyst is unknown or if there is a strong suspicion that it could be cancerous then an open operation is carried out with a midline incision (not a bikini-line incision). If after opening the abdomen it is not immediately obvious whether the cyst is cancerous or not, the whole ovary is quickly removed (which takes only 5 minutes) and sent away for immediate analysis. This is called "Frozen section" analysis. This is not 100% accurate but is said to be 80 to 90% accurate. During a frozen section analysis, the patient is kept anaesthetised whilst awaiting the result which usually takes about 30 minutes. If the pathologist reports a benign cyst then nothing further is required and the patient is closed up again unless they want to have a hysterectomy and other ovary removed anyway.

If the pathologist reports a cancerous cyst then the surgeon proceeds to carry out a full hysterectomy, removal of the other ovary and takes out other tissues. These include the omentum (apron of fatty tissue hanging from the bowel), pelvic and para-aortic lymph glands, appendix and any other suspicious areas. The aim of the operation is to leave the patient with no visible signs of tumour.

Omental nodule
Omentum with cancer infiltration

If on opening the abdomen, it is obvious that there are suspicious tumour deposits such as nodules on the omentum, or nodules on the surfaces of the bowel or the diaphragm then the surgeon proceeds to take all these deposits out without asking for a frozen section analysis. A hysterectomy is also completed. Under these circumstances, it is sometimes found that the bowels are significantly affected with the cancer and hence bowel surgery  is carried out to resect these segments of the bowel. In some circumstances, the end portion of the large bowel (rectum and sigmoid colon) which is most commonly affected is removed. Continuity in the bowel is  restored by joining up the cut ends of the bowel but in many instances, this join has to be rested from any traffic of bowel motions and hence a temporary stoma bag is created. This bag is reversed after about 6 months when the chemotherapy has been completed.

Pelvic stripping
Pelvis stripped of its cancerous lining

Once again, the aim of the surgery is to leave the patient with no traces of visible tumour but this is not always possible! In that case the surgeon aims to remove all large deposits of tumour so that any residual tumour does not have a size greater than 1 cm. The surgery to render the patient with no visible cancer can be quite extensive and long and can sometimes take 4 to 6 hours. In this time large areas of the peritoneum (the skin covering the inside organs) is carefully stripped away as this often harbours the visible deposits of tumour. Sometimes the peritoneal nodules are in awkward positions such as the diaphragms and the liver is therefore carefully retracted aside in order to remove these plaques of disease!

Diaphragmatic stripping
Diaphragm stripped of its cancerous lining

After this kind of extensive surgery, the patient is discharged home after about 6 to 7 days. Once the results confirm an ovarian cancer in that time preparations are made to start chemotherapy within the next few days! The chemotherapy is given as a drip lasting about 3 hours every 3 weeks for about 6 cycles and hence lasting about 5 months.

In some circumstances when the patient first presents with symptoms, if the initial CT scan shows a lot of cancer disease in the abdomen then a decision is made to start with chemotherapy rather than surgery. Therefore, half the chemotherapy (3 cycles) is given upfront after which the extensive surgery is carried out followed by the rest of the chemotherapy. To enable this strategy, it is necessary to confirm the diagnosis of ovarian cancer first. This is done by asking a radiologist to carry out a biopsy of a suitable nodule under ultrasound or CT guidance. Occasionally, a radiologist is unable to carry out this biopsy and hence the patient undergoes a laparoscopy under general anaesthetic.

Mesenteric nodules
Tumour nodules on the small bowel is often unresectable

 

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